Online peer support for mental health in individuals with post‐acute sequelae of COVID‐19: A pre‐post pilot study with mixed methods

Abstract Aim This pilot examined the effect of online peer support on mental health problems among individuals with post‐acute sequelae of COVID‐2019 (PASC). Methods A single‐arm pre‐post design of online peer‐support design consisting of eight sessions of 1 h per week with three to six participants and two facilitators per group was performed. Participants were recruited from online communities, social media, and medical clinics for the PASC between May and August 2023. The degrees of depression, anxiety, loneliness, social withdrawal, and self‐esteem were measured pre‐ and post‐intervention. Participants' statements during the sessions were analyzed using thematic analyses. Results Of the 18 participants, three dropped out of the interventions, and 17 (including two participants who dropped out) completed the pre‐ and post‐intervention questionnaires. Depression severity significantly decreased in the paired t‐test and linear mixed model. The following interactions were extracted: conveying the same feelings, dealing with difficulties, showing empathy, enhancing the atmosphere, and adapting to suit health conditions. Impressions extracted from participating in the interventions included feelings of emotional support, a sense of bonding, changes in perspective, changes in behaviors or new actions through participation, inadequacy during sessions, and adverse effects associated with participation. Conclusion Online peer support may be helpful in treating depression in individuals with PASC.


INTRODUCTION
Post-acute sequelae of coronavirus disease 2019 (COVID-19) (PASC) is defined as the maintenance, relapse, or emergence of symptoms beyond 4 weeks after COVID-19 infection, such as fatigue, brain fog, dizziness, and gastrointestinal symptoms. 1,2Of individuals with COVID-19, 12.44% had at least one symptom of PASC. 3 The burden of health loss is substantial, with 35%-69% of PASC persisting for over 2 years. 4ntal health problems, often observed in those with PASC, are suggested to affect prolonged PASC.Approximately 23% of patients with PASC have mental health problems, 5 and association between PASC and mental health problems has been noted. 6,7In addition to PASC often observed in those with preexisting mental health problems, 8,9 PASC itself is suggested to contribute to mental health problems. 10They may be promoted by psychosocial burdens secondary induced by PASC, such as the inhabitation of work ability 11 and stigma. 12,13Considering mental health problems are suggested to prolong PASC from longitudinal studies, [14][15][16] decreasing mental health problems among individuals with PASC is crucial.
In addition to psychological intervention, 17,18 physical rehabilitation, 18,19 exercise, [20][21][22] and non-invasive cognitive stimulation, [23][24][25] online peer support is suggested to be useful for mental health problems in individuals with PASC when conducted with trained facilitators.Online peer support, recommended by several national health organizations for PASC as a strategy to address psychosocial aspects, consists of regular meetings via online video systems for individuals experiencing similar difficulties. 26,27Considering the difficulties that individuals with PASC may face in commuting to medical institutions because of their symptoms, 28 participating in online peer support may be a more practical option than face-to-face peer support.According to a qualitative study, participants complemented the treatment gap by obtaining insights, behavioral engagement, diversity, social connection, and delivering or obtaining support through a peersupport group. 29,30The effects of peer support on mental health have also been demonstrated in other populations.Online peer support during the COVID-19 pandemic has also been reported to be helpful for mental health in populations other than those with PASC. 31On particular, peer-support groups with trained facilitators have been shown to increase the effects, as indicated by a systematic review identifying accelerators of peer-support groups. 32wever, to our knowledge, the effects of regular online peersupport group meetings with trained facilitators on individuals with PASC have not yet been examined.A systematic review indicated that few studies have examined the effect of online peer support for PASC via regular meetings with trained facilitators. 33To date, although two studies have reported that self-management programs containing online peer-support sessions improve psychosocial problems, 34,35 neither examined the effect of peer-support sessions alone.One study focused online communities for PASC providing communication services by text message or video at any given time, but how many and how much participants utilized the services were unknown. 34In another study, the main intervention was cognitive behavioral therapy lectures over regular sessions and an online peersupport group that was optional and unstructured in terms of participants, times, and medium. 35Hence, the effects of a peer-support group with regular sessions remain unclear.Moreover, although some experiences through peer-support groups for PASC have been identified, 29 it may be incomprehensive owing to the lack of information regarding negative experiences and the interactions between individuals during peer-support sessions.
This study aimed to examine the effect of online peer support at regular meetings with trained facilitators on the mental health of individuals with PASC.Additionally, subjective experiences and impressions of online peer-support sessions and interactions during sessions were examined using qualitative methods to explore the elements that impact the effect.

Study design
This pilot study employed a pre-and post-single-arm design of online peer support for over 8 weeks.Participants responded to online questionnaires using Microsoft Forms three times: on participant agreement, before starting the intervention, and after finishing the intervention.Participants' statements during all intervention sessions were also recorded using the Zoom recording system, which was used to hold the groups and collect them for qualitative analyses.Participants who were absent from more than half the sessions were identified as dropouts.

Participants
The sample size was required to be 18 or more, based on the sample size criteria for pilot studies. 36

Measurements
Patient Health Questionnaire-9 The Patient Health Questionnaire-9 (PHQ-9) was used for assessing the severity of depression, the primary outcome.It consists of nine items with a four-level Rikert scale (0-3). 37,38A total score of 5 or more indicates mild depression.This scale was collected at participant agreement and pre-and post-intervention.

General Anxiety Disorder-7
The General Anxiety Disorder-7 (GAD-7) scale was used to assess the severity of anxiety (a secondary outcome).It consists of seven items with a four-level Rikert scale (0-3). 39,40Higher scores indicate severe anxiety.Data were collected pre-and post-intervention.

Three-item loneliness scale
A three-item loneliness scale was used to assess the severity of subjective loneliness (a secondary outcome), consisting of three items with a three-level Rikert scale (1-3). 41,42Higher scores indicate severe loneliness.Data were collected pre-and post-intervention.

Luben Social Network Scale
The Luben Social Network Scale (LSNS) was used to assess the severity of social withdrawal (a secondary outcome).4][45] Higher scores indicate severe social withdrawal.Data were collected pre-and postintervention.

The Rothenberg Self-esteem Scale
This scale, consisting of 10 items with a four-level Rikert scale (1-4), was used to assess the degree of self-esteem (a secondary outcome).
Higher scores indicate higher self-esteem. 46,47Data were collected pre-and post-intervention.

Others
Age, 48 gender (male, female, or other), 49 psychiatric history, duration since infection, 50 vaccination for COVID-19, 51 and time of participation in peer-support group sessions were collected as covariates.
These items were obtained during the participant agreement.

Intervention
Online peer support consisted of eight sessions, 1 h per session per week.All sessions were conducted using Zoom (Zoom Video Communications, Inc.).At the time of enrollment, each group consisted of three to six participants and two facilitators (M.M. and M.H.): a psychiatric nurse and a clinical psychotherapist, who were supervised by a peer-support specialist at every session.The details of these sessions are listed in Table 1 were identified as dropouts.Significant outcomes were further analyzed with paired-t tests and Cohen's d as supplementary analyses, restricted to those without psychiatric history to determine if psychiatric history influenced the changes.Post hoc power analyses for paired-t tests were also performed.
The data of participants who were lost to follow-up were excluded using paired t-tests and included in the linear mixed method.
Quantitative analyses were performed using Stata 18.0.Statistical significance was set at P < 0.05.
A thematic analysis approach was employed for qualitative data, focusing on interactions while participating in peer-support groups and thoughts on participating in peer-support groups. 52

Participants
As shown in Figure 1
Table 3 shows  No significant changes in outcomes, other than depression, were observed.

Qualitative experiences
For interactions while participating in peer-support groups, five themes with 10 subthemes were extracted (  Pleased by the empathy of others "I'm really grateful that you understand and empathize with me as if it were your own issue." The pleasure of finding out others have the same feelings "It was really good to have this kind of opportunity, as it's been difficult to meet people who are going through similar experiences." Building a sense of bonding The group's existence as a support "I was especially looking forward to later sessions, …, naturally, it feels like my mood has lifted a bit in anticipation of this day." Feeling a sense of solidarity "For 2 months, I've felt a strong sense of camaraderie with XXX-san and XXX-san, as if we've been working together in tandem…" Being able to speak honestly "Since I've been lying to everyone around me, it was a relief that I didn't have to tell any lies today." Glad to encourage someone "Currently, I'm the one receiving a lot of encouragement, but the fact that I can encourage others is something that really makes me happy." Change in perspective Gaining new insights "I've received a really good perspective, wondering if even now, there might be things I can do aimed at growth, personal growth." Becoming more positive "At first, I was really down, like I couldn't see the goal Viewing oneself objectively "Through an objective lens, I've come to reaffirm, by listening to everyone's stories, that there indeed are times when I can't move much and that it's a phase where I'm unable to be active."

Change in behavior or new actions
Becoming a catalyst for taking new actions "Hearing about how everyone spends their time, I thought about creating moments to step away from social media and try different ways to spend my time."

DISCUSSION
To the best of our knowledge, this is the first study to examine changes in mental health conditions among individuals with PASC through online peer support conducted at regularly scheduled times with trained facilitators.A significant change in depression severity was observed from pre-intervention to post-intervention.Interactions during online peer support were extracted as follows: conveying the same feelings, dealing with difficulties, showing empathy, enhancing the atmosphere, and adapting to suit health conditions.
Participants reported impressions of peer-support groups, including emotional support, a sense of bonding, a change in perspective, a change in behavior, and new actions through participation.However, they also felt inadequate during the sessions and experienced adverse effects associated with participation.
A small to moderate effect on depression severity was observed from pre-intervention to post-intervention, indicating that regularly scheduled online peer support with trained facilitators may be mildly effective for individuals with PASC.4][35] While similar results were obtained, the processes might be different between previous studies and this study.
7][58] Although the possibility of depression improvement being caused by the passage of time cannot be denied, online peer support may be practical for the mental health of patients with PASC.
Qualitative analyses revealed interactions for conveying the same experiences, empathy, proposal of coping strategies and information, enhancing the atmosphere by idle talk, presenting different opinions, and accommodating their conditions, which were indicated to occur during the sessions.Additionally, individuals with PASC reported experiencing emotional support, a sense of bonding, and a change in perspective and behaviors through online peer support, as well as negative impressions, such as feelings of inadequate responses, and adverse effects, such as negative impressions about group ending and fatigue during attendance.Impressions of a sense of bonding and emotional support were consistent with impressions extracted in previous studies. 29,307][58] Moreover, interactions like conveying the same experiences and empathy may promote impressions like emotional support and to reduce depression, as sharing experiences and showing empathy generally promote bonding and emotional healing. 59The impression of changes in perspective and behavior may also have positive effects on depression, considering that cognitive behavior therapy aims to promote changes in perspectives and behaviors that worsen depression to alternative ones.Interactions such as the proposal of coping strategies and information and the presentation of different opinions might contribute to changes in behaviors and perspectives.On the other hand, negative impressions like feelings of inadequate responses and adverse effects, such as negative feelings about group ending and fatigue during attendance, were newly identified in this study to our knowledge.These impressions may interfere with depression improvement through online peer support, as inadequate supportive communication and perceived isolation affect mental health. 56,60 significant reductions were observed in anxiety, loneliness, social withdrawal, and self-esteem.Qualitative results suggest that the end of the peer-support groups may have contributed to these outcomes, with participants expressing negative feelings such as anxiety and a sense of loss.2][63] Based on the absence of cutoff point criteria of them, resulting in pre-mean of anxiety severity being below the cutoff of clinical anxiety definition, a potential floor-effect might also exist. 64Future intervention studies should consider not limiting the number of sessions to better address these problems and setting criteria.Replication studies should also be performed with larger sample sizes, given that the absence of significant differences might be attributable to low statistical power, resulting in a type Ⅱ error.
Furthermore, online peer support may overcome the limitations of medical resources and accessibility for PASC. 28Disseminating online peer support for PASC is essential to establish communities that deliver services.Additional care may be implemented based on negative impressions, such as negative feelings toward ending the group sessions, fatigue after attending, and feelings of inadequate response.For example, regular sessions without an ending, sessions with a shorter duration, and consultation services for frustration experienced during the sessions can be proposed.
This study had some limitations.First, we acknowledge that the change in depression observed in this study may have been caused by time elapsed rather than online peer support due to the single-arm design.However, a similar significant change was observed after adjusting for time elapsed after infection.Additionally, there were sampling biases, such as being limited to individuals with high adherence because of voluntary agreement and having characteristics such as being close to online communities and social media.
Representativeness of participants and robustness of results were limited because of the small sample size.Moreover, the accuracy of the presence of PASC was limited, considering that PASC was selfreported and was not diagnosed by physicians.Participants may have impressions other than what they stated, especially impressions that were difficult to express in the presence of other participants (e.g., negative impressions of others' attitudes).Qualitative analyses were performed with minimal subjective bias; however, complete elimination of such bias is difficult.
In conclusion, this single-arm pilot study suggests that online peer support with regular sessions and trained facilitators may be effective for treatment of depression among individuals with PASC.
To confirm this effect robustly, a two-arm randomized controlled trial and a study examining the long-term effects should be conducted in the future.
Recruitment was performed from May 2023 to August 2023 by posting recruitment advertisements on several social network services, such as anonymous online communities for PASC, including three LINE open chat groups containing approximately 100-900 members and a Facebook group containing approximately 30 members, X, and at a medical clinic for PASC.Regardless of the number of sessions attended and discontinuation of participation, participants who completed all three questionnaires received prepaid cards worth JPY 3000 as a reward.Inclusion criteria were (a) 18 years old or older, (b) self-reported as having PASC, (c) a patient-health questionnaire-9 (PHQ-9) score ≥5 to avoid the floor effect and more clearly assess the effectiveness of the intervention, (d) access to an online environment and devices, and (e) having an appropriate talking environment, such as a private room.Exclusion criteria were (a) difficulty in attending all sessions at the time of obtaining consent and (b) the score of the item regarding suicidal intention at PHQ-9 ≥ 2.

1 • 7 • 8 •
. The talk topics of each session were decided by the participants and facilitators in session 1 and before each session based on the pooled desired talk topics raised by the participants in the pre-intervention questionnaire.Examples of talk topics were as follows: how to deal with PASC, psychological distress regarding PASC, difficulty in doing work and household duties, no way to know when PASC will heal, change of life from before to after PASC, and self-image of PASC.The ground rules of the groups were shared with participants before session 1 to promote safe and warm communication.These ground rules included refraining from disclosing group discussions to individuals outside the group without permission, avoiding the promotion of specific treatments or folk remedies, and refraining from discussions related to politics, ideology, and religion.Participants could attend sessions in ways and lengths that facilitated their attendance, considering the PASC, such as leaving the session, late attendance, and lying down.Analyses After Cohen's d for estimating the effect size and the Shapiro-Wilk tests for confirming normality were calculated, the pre-post changes in the outcomes were confirmed via paired t-tests.Sensitivity analyses were also performed using the linear mixed model, which confirmed the change after adjusting for loss to follow-up and covariates, including age, gender, psychiatric history, duration after infection, vaccination for COVID-19, and the time of participation.Intention-to-treat (ITT) and per-protocol analyses were conducted.Participants who were absent from the session more than four times T A B L E 1 Details of the online peer support sessions.Session Topics Announcement of the aim and the experience process of the peer-support group and the ground rules by facilitators • Self-introduction • Determination of talk topics for sessions 2 to 7 • Free discussion • State impressions of the session one by one • Announcement of the next session by facilitators 2-Announcement of the aim and process of the peersupport group and the ground rules by facilitators • State recent conditions one by one • Discussion regarding the topic and free discussion • State impressions on the session one by one • Announcement of the next session by facilitators Announcement of the aim and process of the peersupport group and the ground rules by facilitators • State recent conditions one by one • Discussion regarding the thoughts on participating in the past sessions • State impression on the session one by one • Announcement of asking to respond to the postintervention questionnaires by facilitators PEER SUPPORT FOR POST-ACUTE SEQUELAE OF COVID-19 | 3 of 10 , 18 of 23 enrolled individuals responded to the pre-intervention questionnaire, and 15 completed the interventions after three dropped out, although 17 responded to the postintervention questionnaire.The attendance numbers for each session in peer-support groups are detailed in Appendix S1.Although we aimed for at least three participants per group, the actual sessionswere performed with two or more participants because some individuals did not attend any sessions.Group C was discontinued due to dropout request.These individuals were not included in the analyses as they did not complete the pre-questionnaire.
, or I didn't know what to do, but now, I feel more like thinking about what I could try doing next or what to experiment with." m glad to have learned even a little about everyone's current symptoms and how they communicate to others."Feelings of inadequate responses during sessionsStruggling with how to approach others "Because of that, I was a bit unsure about how to join in the conversation or at what point it would be okay to chime in."Wishing for more exchange of information "I did think it would have been better if we could have set something like this up sooner and had the opportunity to exchange various pieces of information earlier."Adverse effects associated with participation Negative feelings about the group ending "I'm definitely anxious about the future, feeling as if I'm losing allies around me; that's what I think."Feelings of tension and fatigue during participation "Actually, I might have been a bit nervous last week too, because I was extremely tired after the meeting ended, and, yes, I ended up feeling quite drained and had to rest for the rest of the afternoon."Note: XXX-san represents the names of the participants.PEER SUPPORT FOR POST-ACUTE SEQUELAE OF COVID-19 | 7 of 10 Nishi and Megumi Hazumi.Data collection: Megumi Hazumi, Michi Miyake, and Mayumi Kataoka.Formal analysis: Megumi Hazumi and Michi Miyake.Interpretation of data: all.Original draft preparation: Megumi Hazumi.Review and editing: all authors.Supervision: Daisuke Nishi.
Participants reported experiencing six themes with 16 subthemes after participating in peer-support groups (Table4):(1)emotional support, such as feeling relieved through talking, being pleased by empathy from others, and learning that others have the same feelings; (2) building a sense of bonding, such as feeling the group's existence as a support or sense of solidarity, and the pleasure of speaking honestly and encouraging someone; (3) change in perspective, such as gaining new insights, becoming more positive, and viewing oneself objectively; (4) changes in behavior or new actions, T A B L E 3 Pre-post intervention change.Abbreviation: SD, standard deviation.PEER SUPPORT FOR POST-ACUTE SEQUELAE OF COVID-19 | 5 of 10